Vol 44 # 2 June 2012 - Kma.org.kw

More documents

Recommendations

Info

123 Determining the Effect of Sufentanil on Propofol Injection Pain June 2012 DISCUSSION Propofol is a 2,6 disopropyl phenol and like all phenols it irritates the skin , mucous membranes and venous intima. PIP is still a common problem and the ideal method for its prevention is still controversial. Among 33 clinical problems, PIP has been seventh in the list, when both clinical importance and frequency were considered [15] . There are a lot of factors that affect the incidence of PIP. These are site of injection, size of vein, speed of injection, aqueous phase propofol concentration, and the speed of carrier fluid, propofol temperature, syringe material and drugs used before propofol injection. PIP can be immediate or delayed. Direct irritant effect probably causes immediate pain and kinin cascade activation causes the delayed one. Lidocaine and opioids are most used pretreatment drugs for prevention of PIP. Lidocaine decreases PIP by inhibiting bradykinin production via kinin cascade [16] . Its pH and dilution of propofol in the aqueous phase causes less pain. But sometimes lidocaine fails to decrease pain and can cause some side effects like anaphylactic shock developing immediately after intravenous administration of lidocaine without preservative added to the propofol to decrease injection pain [17] . Opioids such as alfentanil, remifentanil and fentanil are reported to decrease PIP [1,3,11,18] . Opioids effect centrally or peripherally [3] . Opioid receptors are found in the dorsal root ganglia, central terminals of primary afferent nerves and in the periphery [19] . Therefore, the pain reduction effect of opioids on PIP might be on peripheral receptors [20] . Several studies have confirmed effect of opioids on PIP. Basaranoğlu et al [18] reported that 1 mcg/kg dose of fentanil and remifentanil are effective in prevention of PIP. Roehm [21] et al compared 0.25 mcg/kg/ min remifentanil with 40 mg lidocaine and found that both were equally effective. Nathanson et al reported that 1 mg alfentanil and 40 mg lidocaine are effective for prevention of PIP [10] . Lyilikci and colleagues found that alfentanil and remifentanil decreased PIP severity and frequency and also that remifentanil should be used in dose of at least 0.02 mg for this purpose [19] . Kırdemir et al concluded that remifentanil 0.5 mcg/ kg and alfentanil 1 mg prevent PIP as effectively as lidocaine [22] . Optimum dose of alfentanil in children that reduced PIP was 15 mcg/kg [23] . Fentanyl 100 μg, preceded by one minute venous occlusion was effective in pain reduction during propofol injection in Japanese adults [24] . Cho reported that the combination of cold propofol (4 °C) and pretreatment with 0.5 μg/kg IV remifentanil more effectively decreased the incidence of pain than either treatment alone [25] . Kwak et al reported the combination of 0.35 μg/kg/min pretreatment with remifentanil and premixture of lidocaine with propofol was more effective in reducing the incidence of pain on injection of propofol than either treatment alone [26] . Aouad et al assessed the combination of two different analgesic modalities (2% 40 mg lidocaine premixed with 180 mg propofol and pretreatment with 2 μg/kg fentanil) [27] and found that both the drugs completely abolished moderate and severe PIP, and significantly reduces the incidence of mild pain when compared with each drug used alone. If all these opioids have a decrement effect on PIP, sufentanil must have the same effect, but at what dosage was our question in this study. Sufentanil has 10-15 times greater potency than fentanil and 50 times that of alfentanil. It has an immediate onset of action. It is used as an analgesic adjunct in the maintenance of balanced general anesthesia in surgical procedures, for the postoperative management of pain following general surgery, thoracic or orthopedic procedures and cesarean sections via epidural route and as an analgesic adjunct to epidural bupivacaine during labor and vaginal deliveries. Its effects on central nervous system, minimal alveolar concentration levels of volatile anesthetics and respiratory depression is similar to the other opioids. Doses more than 2.6 mcg/kg can cause respiratory depression, increase in airway resistance and muscle stiffness after surgery [28] . Its analgesic dose was between 0.01 - 0.03 mcg/kg [29] . Nathanson, Fletcher and İyilikçi et al. showed that PIP decreased 30 seconds after alfentanil and remifentanil [10,11,20] . We injected propofol 30 seconds after sufentanil. Sufentanil decreased overall pain incidence from 92.5 to 70%. Sufentanil at 1 mcg dose decreased PIP to 77.5% and at 2mcg dose to 44.5% and this was significant compared to control group. Chung et al compared 0.1 mcg/kg, 0.2 mcg/kg, 0.3 mcg/kg sufentanil doses 5 minutes before propofol injection [30] . They reported that 0.3 μg/kg reduced the severity of PIP. Honarmand and Safavi, found that pretreatment with sufentanil 1 mcg did not reduce the incidence and degree of injection pain compared with 0.02 mg remifentanil [31] . However, it decreased pain to 75% compared with saline as we found in our study (77.5%). Low sufentanil dose or the insufficient time period of one minute may have caused this difference. Although we injected propofol 30 seconds after sufentanil, sufentanil decreased overall pain incidence from 92.5 to 70%. Sufentanil at 1 mcg dose decreased PIP to 77.5% and at 2 mcg dose to 44.5% and this was significant when compared to the control group. CONCLUSION In conclusion, sufentanil at 1 mcg and 2 mcg doses reduced the incidence and severity of pain on propofol injection. Added to the known advantage of being an adjunct in induction, rapid recovery and lesser need
June 2012 KUWAIT MEDICAL JOURNAL 124 for postoperative analgesia, sufentanil seems to be an effective alternative to lidocaine for the purpose of reducing the incidence of pain related to intravenous propofol. REFERENCES 1. Nathanson MH, Gajraj NM, Russel JA. Prevention of pain on injection of propofol: a comparison of lidocaine with alfentanil. Anesth Analg 1996; 82:469-471. 2. Smith I, White PF, Nathanson M, Gouldson R. Propofol: An update on its clinical use. Anesthesiology 1994; 81:1005-1043. 3. Tan CH, Onsiong MK. Pain on injection of propofol. Anaesthesia 1998; 53:468-476. 4. Tan CH, Onsiong MK, Kua SW. The effect of ketamine pretreatment on propofol injection pain in 100 women. Anaesthesia 1998; 53:302-305 5. Mangar D, Holak EJ. Tourniquet at 50 mm Hg followed by intravenous lidocaine diminishes hand pain associated with propofol injection. Anesth Analg 1992; 74:250-252. 6. Shipton EA. Tramadol - Present and future. Anaesth Intensive Care 2000; 28:363-374. 7. Ambesh SP, Dubey PK, Sinha PK. Ondansetron pretreatment to alleviate pain on propofol injection: A randomized, controlled, double-blinded study. Anesth Analg 1999; 89:197-199. 8. Johnson RA, Harper NJ, S. Chadwick S, Vohra A. Pain on injection of propofol: Methods of alleviation. Anaesthesia 1990; 45:439-442. 9. Eriksson M, Englesson S, Niklasson F, Hartvig P. Effect of lignocaine and pH on propofol-induced pain. Br J Anaesth 1997; 78:502-506. 10. Nathanson MH, Gajraj NM, Russell JA. Prevention of pain on injection of propofol: a comparison of lidocaine with alfentanil. Anesth Analg 1996; 82:469-471. 11. Fletcher JE, Seawell CR, Bowen DJ. Pretreatment with alfentanil reduces pain caused by propofol. Br J Anesth 1994; 72:342-344. 12. Cheong MA, Kim KS, Choi WJ, Ephedrine reduces the pain from propofol injection. Anesth Analg 2002; 95:1293-1296. 13. Dubey PK, Prasad SS. Pain on injection of propofol: the effect of granisetron pretreatment. Clin J Pain 2003; 19:121-124. 14. Pang W, Mok M, Huang S, Hwang H. The analgesic effect of fentanyl, morphine, meperidine, and lidocaine in the peripheral veins: a comparative study. Anesth Analg 1998; 86:382-386. 15. Macario A, Weinger M, Truong P, Lee M. Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg 1999; 88:1085-1091. 16. Picard P, Tramer MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000; 90:963-969. 17. Ismail K, Simpson PJ. Anaphylactic shock following intravenous administration of lignocaine. Acta Anaesthesiol Scand 1997; 41:1071-1072 . 18. Basaranoğlu G, Erden V, Delatioğlu H. Reduction of pain on injection of propofol: A comparison of fentanyl with remifentanil. Anesth Analg 2002; 94:1040-1041. 19. Iyilikci L, Balkan BK, Gokel E, Günerli A, Ellidokuz H. The effects of alfentanil or remifentanil pretreatment on propofol injection pain. J Clin Anesth 2004 ; 16:499-502. 20. Sebel PS, Hoke JF, Westmoreland C, Hug CC Jr, Muir KT, Szlam F. Histamine concentration and hemodynamic responses after remifentanil. Anesth Analg 1995; 80:1990-1998. 21. Roehm KD, Piper SN, Maleck WH, Boldt J. Prevention of propofol-induced injection pain by remifentanil: a placebo-controlled comparison with lidocaine. Anaesthesia 2003; 58:165-170. 22. Kirdemir P, Gogus N: Comprasion of various drugs and techniques in the prevention of propofol injection pain. Gulhane Med J 2002; 44:149-153. 23. Hiller A Saarnivaara L. Injection pain, cardiovascular changes and recovery following induction of anaesthesia with propofol in combination with alfentanil or lignocaine in children. Acta Anaesthesiologica Scandinavica 1992; 53: 564-568. 24. Fujii Y, Itakura M A Comparison of pretreatment with fentanyl and lidocaine preceded by venous occlusion for reducing pain on injection of propofol: A prospective, randomized, double-blind,placebo-controlled study in adult Japanese surgical patients. Clin Therap 2009; 31: 2107-2112. 25. Cho SY, Jeong CW, Jeong CY, Lee HG. Efficacy of the combination of cold propofol and pretreatment with remifentail on propofol injection pain. Korean J Anesthesiol 2010; 59:305-309. 26. Kwak K, Kim J, Park S, et al. Reduction of pain on injection of propofol: combination of pretreatment of remifentanil and premixture of lidocaine with propofol. Eur J Anaesthesiol 2007; 24:746-750. 27. Aouad MT, Siddik-Sayyid SM, Al-Alami AA, Baraka AS. Multimodal analgesia to prevent propofol-induced pain: pretreatment with remifentanil and lidocaine versus remifentanil or lidocaine alone. Anesth Analg 2007; 104:1540-1544. 28. Chang J, Fish KJ. Acute respiratory arrest and rigidity after anesthesia with sufentanil: a case report. Anesthesiology 1985; 63:710-711. 29. Miller R, Fleisher LA, Eriksson LI. Miller’s Anesthesia. 7th ed. Philadelphia, Churchill-Livingstone Elsevier. 2010, pp 769-814. 30. Chung DH, Kim NS, Lee MK, Jo H. The effect and optimal dose of sufentanil in reducing injection pain of microemulsion propofol. Korean J Anesthesiol 2011; 60:83-89. 31. Honarmand A, Safavi M. Prevention of propofolinduced injection pain by sufentanil: a placebocontrolled comparison with remifentanil. Clin Drug Investig 2008; 28:27-35.
Page 1 and 2: VOLUME 44 NUMBER 2 KMJ KUWAIT MEDIC
Page 3 and 4: Kuwait Medical Journal (KMJ) Publis
Page 5 and 6: Instructions for Authors (if applic
Page 7 and 8: June 2012 KUWAIT MEDICAL JOURNAL 90
Page 15 and 16: June 2012 In many subjects with poo
Page 27 and 28: June 2012 students experience lower
Page 39: June 2012 KUWAIT MEDICAL JOURNAL 12
Page 59 and 60: June 2012 Timely diagnosis and drai
Page 91 and 92:
June 2012 KUWAIT MEDICAL JOURNAL 17
Page 93 and 94:
Page 95 and 96:
show all

Vol 44 # 2 June 2012 - Kma.org.kw

Create successful ePaper yourself

Delete template?

Save as template?